Monday, February 27, 2017

Q: What is the usual cut off point in size to consider immediate drainage for renal abscess and perirenal abscess respectively? Answer: 5 cm and 3 cm respectivelyThough both starts as tissue necrosis due to infection, renal and perinephric abscess are two different processes, at least in terms of location, which may make managements little different. A renal abscess is a walled-off cavity inside the kidney, and the perinephric abscess is relatively a liquefied substance lying between the renal capsule and Gerota’s fascia. Renal abscesses can be managed conservatively until the size is about 5 cm, but perinephric abscesses should be drained relatively early at around 3 cm. This is just a rule of thumb, as smaller abscesses may require percutaneous or surgical interventions if antibiotics remain ineffective.This leeway is due to the reason that renal abscess usually responds well to a proper antibiotic regimen, as well as drainage can be relatively difficult. Also, as perinephric abscesses do not communicate with the collecting system, there is no other way to obtain culture/microorganism except direct intervention to tailor proper antibiotics.

Q: Gastric-arterial pCO2 gradient continues to remain a controversial parameter to measure in septic shock. Given, if it is use in clinical practice, what is the cutoff level to designate patient at high risk of dying from septic shock? Answer: 15 mm HgGastric-arterial pCO2 gradient has been suggested as a prognostic marker in patients with septic shock, as it may measure the end organ ischemia. Gastric PCO2 is measured by gastric tonometry, which indirectly measures the perfusion to the gut. Theoretically, trending gastric to arterial PCO2 gap should reflect the end organ ischemia, but evidence based literature failed to show its clinical relevance. On similar line, attempts have been made to calculate and trend gastric PCO2-(End-tidal) PCO2 gap, but so far there is no real success.

Sunday, February 26, 2017

Q: What is the most common causative organism associated with non-central line associated jugular vein suppurative thrombophlebitis?Answer:Fusobacterium necrophorumJugular vein suppurative thrombophlebitis, commonly known as Lemierre's syndrome is usually caused by either central line or extension of oropharyngeal infection. Causative organisms are different respectively.Clinical significance: Initial empiric treatment for Fusobacterium necrophorum should include a beta-lactamase resistant beta-lactam antibiotic like ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate or a carbapenem. Jugular vein suppurative thrombophlebitis secondary to central line catheter should include vancomycin in the initial empiric therapy to cover skin flora.Later antibiotics can be tailored and narrowed according to culture and sensitivity.

Saturday, February 25, 2017

Q: What is NCDR CathPCI risk score?

Answer: National Cardiovascular Data Registry (NCDR) for percutaneous coronary intervention (PCI) is a model to predict initial risk in patients with coronary artery disease undergoing PCI. It was developed from little less than 200,000 patients over 3 years across United States. It took into account of 21 variables including age, CHF status, renal insufficiency, PVD, respiratory status, and level of EKG status (STMI or NSTMI), and others.It is a very strong data (C-Index). Patients were equally divided into two arms - patients with acute coronary syndrome and stable patients. Overall in-hospital mortality following PCI was 0.65 percent in elective cases and 4.81 percent in ST-elevation MI patients.

Thursday, February 23, 2017

Q: Vasospasm usually occurs after day 3 in subarachnoid haemorrhage (SAH). What is the main risk factor of vasospasm happening within first 3 days of SAH? A) Severe SAH B) Female genderC) Young age D) SmokingE) Prior SAHAnswer: EIt is true that all of the above increase the risk of vasospasm in SAH, but it usually occurs from day 3 to day 21, peaks around day 7 and risk subsequently decreases after day 12-14. But with patients who have prior SAH (may have gone unnoticed), there is a high risk of vasospasm happening before day 3.

Wednesday, February 22, 2017

Q: All of the following are risk factors of exacerbation of Tricuspid Regurgitation (TR) after insertion of endocardial pacemaker/defibrillator?A) Impingement of leads on a tricuspid valve leafletB) Tethering of leads to the leaflet of tricuspid valves C) Perforation of leads via leaflet of tricuspid valvesD) Entanglement of leads with subvalvular chordae E) Placement of leads in a commissure

Answer: E

Tricuspid Regurgitation continues to fumble cardiologists/physicians as any damage to tricuspid valve (TV) can be irreversibly catastrophic. Literature is ripe with debate on repair vs replacement of TV, as even a minor difference in clinical judgement can have a long-term trajectory effect. All of the above choices can increase or cause (TR) except choice E.Actually one of the ways to avoid damage to TV is to secure placement of leads in a commissure, at a place outside the valve annulus, or replacement with epicardial leads.

Tuesday, February 21, 2017

Q: Oxygen works as an afterload reducer for right-sided heart failure in cor pulmonale? A)True B) FalseAnswer: A

Oxygen therapy acts as a reversal against vasoconstriction secondary to hypoxemia. Subsequently, it decreases pulmonary artery pressure. In fact, oxygen is considered as a drug of choice for pulmonary hypertension secondary to COPD/Cor pulmonale.

Monday, February 20, 2017

(A relatively less discussed issue in ICU - sleep pattern in critically ill patients) "....it is possible that the modern critical care experience—including acute illness, a nontherapeutic environment for sleep and wakefulness, and exposure to multiple medications affecting neurotransmitter balance—engenders new sleep disturbances that persist in some subjects after intensive care. This is similar to the development of new or worsening cognitive function after critical illness and reflects shared mechanisms in the brain. Thus, there is a need for well-designed prospective studies that characterize sleep and circadian disruption throughout critical illness and recovery while examining their relationship to long-term neuropsychiatric outcomes."Read:Sleep in the Intensive Care Unit - A. Pisani & Coll. - American Journal of Respiratory and Critical Care Medicine Home - Vol. 191, No. 7 | Apr 01, 2015

Friday, February 17, 2017

Q: When all measures fail in acute exacerbation of idiopathic Pulmonary Fibrosis (AE-IPF), lung transplant should be pursue aggressively as a last resort of salvage therapy..A) TrueB) FalseAnswer: B

Lung transplantation in IPF has sown good outcome only if its done as an elective process. It should not pursue as a salvage therapy in AE-IPF. It carries a very high mortality rate. Lately, some centers are using extracorporeal membrane oxygenation (ECMO) as a bridge to transplant (BTT) in AE-IPF, but data is still very thin. Ideally, all patients with IPF should undergo transplant evaluation while they are clinically at their baseline.

Thursday, February 16, 2017

Q: What is Phlebosclerotic colitis?Answer: Phlebosclerotic colitis is a form of ischemic colitis that results from venous obstruction, usually involving right side of the colon. It is hallmarked by fibrotic sclerosis and calcification of the walls of the mesenteric veins. It can be diagnosed or at least suspected on plain films (KUB), if linear calcifications are seen in the region of the right colon. Diagnosis can be confirmed by CT scan, with colonic wall thickening and mesenteric venous calcifications. This is usually self-limiting and resolve spontaneously, only requiring supportive treatment.

Wednesday, February 15, 2017

Q: How lupus and antiphospholipid syndrome (APS) can be differentiated from Heparin Induced Thrombocytopenia (HIT)?Answer:

1. Lupus usually causes only mild thrombocytopenia and almost never drops platelet count below 50,000/microL. Moreover, lupus-associated antiplatelet antibodies do not activate platelets and do not cause thrombosis.2. APS, like HIT can cause arterial and venous thrombosis but can be differentiated from HIT

by interaction of APS antibodies with phospholipids i.e cardiolipin and ß2-GP-I

Sunday, February 12, 2017

Q; Recently for Therapeutic Hypothermia, 36°C for 24 hours has been recommended for otherwise non-complicated patient in coma after cardiac arrest. In which situations still lower temperature at 33°C for 24 hours is recommended?Answer: Studies have shown similar outcomes in non-complicated patients with either 36°C or 33°C for 24 hours. 36°C is sufficient for patients

Friday, February 10, 2017

Q: What is the half-life of transfused cryoprecipitate?Answer: Half-life of transfused cryoprecipitate is about two to four days.

Fresh-Frozen -Plasma is thawed at 4°C for about 24 hours, which makes precipitates of cold-insoluble proteins, which are very rich in blood coagulation factors. This product can be kept frozen at -18°C for about one year to use for clinical transfusions. After transfusion, it is effective for about 2-4 days.

Tuesday, February 7, 2017

Q: Foley catheter balloon should be inflated with (select one)A) Sterile water B) Normal Saline Answer: Sterile waterFoley catheter balloon should be inflated with sterile water (after urine flow is confirmed). Normal Saline should never be used to inflate the Foley catheter balloon because it may cause crystal formation, obstruct the balloon channel and later prevent the deflation of balloon.
Reference:Daneshmand S, Youssefzadeh D, Skinner EC. Review of techniques to remove a Foley catheter when the balloon does not deflate. Urology 2002; 59:127.

Monday, February 6, 2017

Q: What is the recommended oxygen saturation in a post drowning patient? A) 88% B) 90% C) 92% D) 94% E) 100%Answer: D (94%) In post drowning patients higher than normal pulse-ox saturation or PO2 (60 mmHg) is recommended as tissue hypoxia is the major cause of the fatality. While managing hypoxia in post drowning patient, at least three points should be kept in mind

There should be a low threshold for intubation and beside hypoxia, even mild to moderate hypercarbia requires intubation at PCO2 50 mmHg (some even suggests more than 45 mm Hg)

In comparison to other patients, the orogastric tube is almost mandatory in post drowning patients as gastric distension may hamper ventilation.

Positive pressure ventilation (PPV) with higher PEEP is recommended but it comes with its own price in post drowning patients, as the line of demarcation between hypotension due to PPV and therapeutic oxygenation is very thin, and requires particular monitoring post intubation.

Sunday, February 5, 2017

Q; In patients with a history of alcohol abuse which three vitamins required to be replaced on relatively urgent basis after admission?Answer:

Thiamine 100 mg daily,

Vitamin B6 2 mg daily, and

Folic acid 1 mg daily

Another difference between other patients and patients with ETOH abuse is, they require frequent feedings, with the goal of an energy intake of 35 to 40 kcal/kg of body weight/day and protein intake of 1.2 to 1.5 g/kg of body weight/day.

Reference: The European Society for Clinical Nutrition and Metabolism (ESPEN). ESPEN Guidelines. http://www.espen.org/espenguidelines.html

Saturday, February 4, 2017

Q: In patients with Aplastic Anemia transfusions should only be given from close family members?A) True B) FalseAnswer: B (False)Ideally, patients with Aplastic Anemia should not receive blood product transfusions from a sibling or a family member, to minimize the risk of an immune reaction to donor antigens, as in the case of Hematopoietic Cell Transplantation (HCT), which may lead to graft failure.

Thursday, February 2, 2017

Q: How far cuff of endotracheal tube should be placed to prevent vocal cord palsy?Answer: At least 15 mm below the vocal cordsVocal cord palsy is an undesired, though rare but a serious complication of endotracheal intubation. The anterior branch of recurrent laryngeal nerve traverses between the lamina of thyroid cartilage and laryngeal mucosa. Overinflated cuff of ET-Tube may compress to cause vocal cord paralysis. First 10 mm of the area below vocal cord is most sensitive for damage. Ideally, ET-tube cuff should be at least at 15 mm below the vocal cords.

Wednesday, February 1, 2017

Q: What one advantage urinary trypsinogen activation peptide (TAP) has over amylase and lipase in acute pancreatitis? Answer: Trypsinogen activation peptide (TAP) is a five amino-acid peptide elevated in acute pancreatitis. It is cleaved from trypsinogen to become active trypsin. Though it may only be of academic interest but it is one of the earliest marker of acute pancreatitis, as well as it co-relates with severity of acute pancreatitis.